Making a Difference
Dorothy Baldwin is a 78 year old widow with Chrohn's disease, a parastomal hernia, osteoarthritis, hypertension, bilateral lower leg lymphedema with open lesions/ulcers, and morbid obesity. She has had an ileostomy, is in chronic pain, and is at high risk for falls. She was recently admitted to an acute care surgical unit via the emergency room to rule out a possible bowel obstruction as the cause of her severe abdominal pain with nausea and vomiting.
Mrs. Baldwin lives alone in a two-story home. Her daughter lives nearby and is Mrs. Baldwin's primary caregiver. Mrs. Baldwin does not meet eligibility criteria for Medicare-reimbursed visiting nurse or physical therapy services. Before discharge, the patient fails to receive consults from either infectious disease or dermatology although such consults have been recommended. Mrs. Baldwin's daughter is not included in any patient teaching, care plan development, or conversations regarding her mother's discharge instructions. The discharge instructions that are provided are general and not customized to Mrs. Baldwin's personal care needs.
Thousands of patients, just like Dorothy Baldwin, are being discharged from hospitals each year. They are returning to their homes without plans for timely medical follow up, basic health care services or community support. These transitions are characterized by inadequate communication, inadequate discharge planning, and serious gaps in care during transfers to and from hospitals all leading to preventable declines in health status. These poor "hand-offs" are extremely common, especially for the chronically ill high-risk older adult population. As a result, rehospitalization is frequent and seemingly inevitable for these patients.
While this scenario is too frequent, an evidence-based alternative model of care is available: the Transitional Care Model. Tested and refined over twenty years by a multidisciplinary team at the University of Pennsylvania, TCM has improved health outcomes, prevented avoidable rehospitalizations, and enhanced patient and family caregiver satisfaction.
For clinicians, working as a Transitional Care Nurse provides an alternative to traditional careers in nursing. And obtaining these services for patients like Mrs. Baldwin results in better health care outcomes and improved patient and family satisfaction.